Acute Headache – 4 (Wrapping Up)

Reviewing our discussion of ACUTE HEADACHE (less than 3-4 weeks duration), & moving on to wrap it up:





It’s a busy day at work.  We pick up a chart (or eyeball the computer screen if into electronic records), & notice that our next patient is here for “Headache.”  Some immediate rule-outs:

  • Age <50 means no temporal arteritis [if older, & new H/A, will order a sed rate];
  • Blood pressure isn’t sky-high [no hypertensive emergency];
  • No fever [not meningitis, CNS infection, or RMSF].

As we enter the room & greet the patient, we see they look comfortable [not acute glaucoma].  There are other rare, horrible causes of acute headache I haven’t discussed, such as carotid or other vascular dissections, cerebral venous thrombosis, hemorrhagic stroke, and more.  But these patients either look obviously sick, or have abnormal neurological exams.

So we begin our history, focusing initially on chronology.  As we establish this is a new “Acute Headache,” not chronic and not recurrent, we realize that this is not the ‘worst headache ever,” or if it is, it didn’t reach maximal intensity within 1-2 minutes [not a SAH].

In the course of our visit, we’ll ask a few target questions, & make some key observations, to rule out other life-threatening conditions in the “Do Not Miss” column:

  • No trauma within the last 1-2 days [not an epidural hematoma];
  • The setting doesn’t suggest carbon monoxide (breathe easier);
  • There’s no dyspnea on exertion [won’t be an acute or severe anemia];
  • No prior high risk-factors for HIV, no HIV stigmata on exam [unlikely AIDS-related];
  • We observe that history is straight-forward and makes sense, thus no reason to suspect occult suicidality.

In the backs of our minds, we’ll wonder if this is one of the very few “headaches” which might warrant an image:

  • Occur daily and progress in severity;
  • Are associated with daily nausea / vomiting;
  • Worsen with valsalvas or bending forward (as a prominent feature, and in association with one of the above, or with age >50);
  • Elderly, or taking anticoagulants, especially if they’d had even the most minor of head trauma within the past few months.

Digression — if you think the patient warrants an image, order a non-contrast head CT.  It’s extremely sensitive for bleeds.  In terms of tumors, it will find masses large enough to cause a headache.  You need an MRI for patients with altered mental status, abnormal neuro exams, or new seizures [small tumors provoke these], or to R/O stroke, but not for “headache.”.

Obviously we’ll perform a decent targeted Neuro Exam, mainly Mental Status and Cranial Nerves (especially the eyes), screening the other components (evaluating Motor & Coordination in depth if our patient complains of bona fide weakness or imbalance).  But if they look well by gestalt, we pretty much know we’re not going to find anything.  It’s our history that’ll make the diagnosis.

Think of the differential diagnosis list.  For each diagnostic possibility, ask a question or two, and perform a brief exam, to rule it in or out.  Be as systematic as possible — ask all your nasal questions together, all your neck-strain ones, etc.  That way you won’t forget.  We’ve already ruled out the “Do-Not-Miss’s.”

For URI / allergic rhinitis (common) or sinusitis (not so common) — is there nasal discharge, congestion, or sneezing?  Is the headache primarily frontal or facial?  Do we see any clues on exam?  We address these specifically in our post Nasal Congestion.

Beware — “acute sinusitis” is a terribly overused diagnosis which lacks decent clinical gold standards, & generates prescriptions for future antibiotic resistance.  If you feel obligated to prescribe something for the nose, call it “allergic rhinitis.”

For a neck strain or sprain: Does a major component of the headache include the neck?  Is there pain with range of motion; do you elicit tenderness of paracervical muscles or trapezii?  Just realize that if you identify the neck as culprit, percuss the cervical vertebrae one-by-one to be sure there’s no bone disease like an osteo or a met (for assessing musculoskeletal complaints in general, see postings Back & Neck Pain,  and Musculoskeletal Pain).

We’d routinely obtain a medication & substance history anyway, which would alert us to a medication overuse syndrome (isn’t it fun to realize how opioids and even NSAIDs not only treat, but also possibly cause, headaches?).  Substances can cause headache during use, or during withdrawal.  Obtaining a good chronology is the key here.

By “physiologic headache,” I mean a normal response to hunger, thirst, weather, fatigue, stress, etc.  It’s not unusual for people to seek care for a new headache occurring summer afternoons; they think “Tylenol helps,” whereas it’s really the glass of water that gained relief.

It’s very difficult (actually, impossible) to diagnose migraine, cluster, or tension headache during the first-ever episode.  The latter isn’t as problematic, because there are no red flags.  But a new migraine or cluster headache, possibly severe, with nausea and/or eye symptoms, might easily suggest an entity in the DO NOT MISS column.  Yet we don’t want to over-order CT’s.

Careful delineation of symptom chronology is the key to most diagnoses in all organ systems.  Migraines build to a maximal intensity over 30-60 minutes, not 1-2 like an SAH.  An episode commonly lasts 8-72 hours.  Cluster headaches begin abruptly, but last less than 3 hours, remit, and recur.

These time frames should help avoid complex, expensive work-ups for patients who happen to present with their first migraine or cluster headache.  Yes, there are “atypical” syndromes which mimic dangerous diseases at the very beginning, but those cases are rare.  If every 5-10 years I subject a patient to a negative spinal tap, I don’t feel bad at all.  And actually, those patients I can think of don’t feel bad either.

Many patients with a new “Acute Headache” may not offer a clear-cut diagnosis.  With a normal neuro exam and no red flags, we probably suspect “tension headache” [next posting, “Recurrent Headaches”].  I suggest that to the patient, recommend whatever sort therapeutic relief I happen to fancy, and especially reassure them they don’t have a ‘brain tumor’.  Always remember to say, “If you get worse, come back.”

Every time I send a patient home, I advise three levels of follow-up:

  • On a certain date no matter what (or specifically decide no follow-up necessary);
  • “But come back in ___ weeks [days, years, etc.] if you’re not getting better;” and
  • “Come back even sooner if you’re getting worse.”

In medical parlance, this is “disposition.”  Disposition is good, “disposing” isn’t.

See also our other postings on the topic: Acute H/A – 1 (“worst ever”), Acute H/A – 2 (masses, & the neuro exam), Acute H/A – 3 (other “not to miss”), Recurrent Headaches, and Chronic Headaches.

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